Provider Demographics
NPI:1750599759
Name:HERRGORD, BRADLEY CARL (DC)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:CARL
Last Name:HERRGORD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-2007
Mailing Address - Country:US
Mailing Address - Phone:916-645-3890
Mailing Address - Fax:916-645-1692
Practice Address - Street 1:1105 EAST AVE
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:CA
Practice Address - Zip Code:95648-2007
Practice Address - Country:US
Practice Address - Phone:916-645-3890
Practice Address - Fax:916-645-1692
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21360111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC21360OtherCHIROPRACTIC LICENSE